Interventions: Disease Prevention and Antimicrobial Use Reduction - Overview

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1 Global Antibiotic Resistance Partnership South Africa Inaugural meeting. Stellenbosch, South Africa 8-9 Feb, 2010 Interventions: Disease Prevention and Antimicrobial Use Reduction - Overview Iruka N Okeke

2 Papers cited in the presentation Walker et al. Science Sep 11;325(5946): van de Sande-Bruinsma N, et al. Antimicrobial drug use and resistance in Europe. Emerg Infect Dis Nov;14(11): Källander Balancing improved access to antibiotics and containment of bacterial resistance. Paper for discussions at the meeting Will we respond to antibiotic resistance in time? Uppsala Sept 14-17, Okeke et al (2007) Emerg Infect Dis, 13 (11) Taylor et al (2001) The Lancet, 357, 1933 Becker et al (2002) Lancet Infect Dis, 2, Okeke and Lamikanra (1995) Int J.Antimicrob Ag 5, 245. Okeke et al (1999) Emerg Infect Dis 5, 18 Wright et al Lancet May 30;373(9678): Scaling up the response to infectious diseases. WHO/CDS/ Okeke IN, Klugman KP, Bhutta ZA, Duse AG, Jenkins P, O'Brien TF, Pablos-Mendez A, Laxminarayan R. Lancet Infect Dis Sep;5(9): Okeke, Fayinka and Lamikanra (2000) Emerg Infect Dis, 6, 393 Goldie et al. N Engl J Med Sep 14;355(11): Mintz ED, Guerrant RL.A lion in our village--the unconscionable tragedy of cholera in Africa. N Engl J Med Mar 12;360(11): Opintan, JA, Newman MJ, Nsiah-Poodoh, OA, and Okeke IN (2008). J Antimicrob Chemother 62, Microbial life.

3 We need more penicillin and Bibles. Miss Sadie Thompson (1953) García Sánchez JE, et al. Rev Esp Quimioter. 2006;19(4):

4 Looming Global-Scale Failures Walker et al. Science Sep 11;325(5946):

5 ondraftreport

6 Occurrence of fluoroquinolone-resistant E. coli (FQRE) plotted against outpatient use of fluoroquinolone antimicrobial agents in 17 European countries including 95% confidence intervals. van de Sande-Bruinsma N, et al. Antimicrobial drug use and resistance in Europe. Emerg Infect Dis Nov;14(11):

7 The overlapping relationship b/w patients who need antibiotics and those who take antibiotics. Källander Balancing improved access to antibiotics and containment of bacterial resistance. Paper for discussions at the meeting Will we respond to antibiotic resistance in time? Uppsala Sept 14-17,

8

9 Okeke et al (2007) Emerg Infect Dis, 13 (11)

10 Substandard antimicrobial medicines from Nigerian pharmacies Taylor et al (2001) The Lancet, 357, 1933 Below Pharmacopoeial limits Chloroquine phosphate % Ampicillin 59-71% Streptomycin 53% Isoniazid 100% Metronidazole %

11 Injectable antibiotics available from market stalls in Kumba, Cameroon Becker et al (2002) Lancet Infect Dis, 2, Ampicillin Benzathine Benzylpenicillin Gentamicin Spectinomycin Lincomycin Ofloxacin Oxacillin Cefuroxime Ceftriaxone Cefotaxime Cefepime

12 Toxic degradation product in dispensed tetracycline capsules Patent medicine stall Roadside stall Patent medicine stall Pharmacy Roadside stall Hospital Manufacturer Anhydrotetracycline content (%) Okeke and Lamikanra (1995) Int J.Antimicrob Ag 5, 245. Okeke et al (1999) Emerg Infect Dis 5, 18

13 Medicines made of heat-stable drugs, such as the quinolones, may still be vulnerable to improper storage, which can change physical properties that affect drug absorption.

14 Heat and moisture Ambient temperatures in some tropical countries may reach C Humidity distorts capsule shells and increases permeability to air and moisture, which can degrade the drug Elevated temperature and humidity change the physicochemical properties of excipients, affecting drug release The packaging of many medicines may be insufficient to protect the medication. Air conditioning is not always practicable

15 Distribution of multidrug-resistant tuberculosis among new cases, Source WHO, Wright et al Lancet May 30;373(9678):

16 The elements of DOTS Scaling up the response to infectious diseases. WHO/CDS/ Okeke et al LID 2005;5(9):568-80

17 Percentage of isolates resistant to each agent over time 1986 (n=63) 1988 (n=156) (n=222) 1996 (n=185) 1998 (n=132) Trimethoprim Sulphonamide Ampicillin Tetracycline Chloramphenicol Nalidixic acid Streptomycin Okeke, Fayinka and Lamikanra (2000) Emerg Infect Dis, 6, 393

18 How can we explain a jump in trimethoprim resistance that occurred in commensal E. coli sometime between 1998 and 2005?

19 Cost-Effectiveness of Treatment Strategies for HIVpositive patients in resource limited areas. Goldie et al. N Engl J Med Sep 14;355(11):

20 Estimated proportion of persons with HIV infection receiving antiretroviral therapy in low-income and middle-income countries as of December Ford N, Mills E, Calmy A. Rationing antiretroviral therapy in Africa--treating too few, too late. N Engl J Med Apr 30;360(18):

21 Mintz ED, Guerrant RL.A lion in our village--the unconscionable tragedy of cholera in Africa. N Engl J Med Mar 12;360(11):

22 Cholera outbreak (Ghana 2006) Jan 2-June 25, 2006 Opintan, JA, Newman MJ, Nsiah-Poodoh, OA, and Okeke IN (2008). J Antimicrob Chemother 62, cases and 79 deaths (4.2% casefatality rate) 27 isolates confirmed V. cholerae O1 Ogawa by reference lab

23 Opintan, JA, Newman MJ, Nsiah-Poodoh, OA, and Okeke IN (2008). J Antimicrob Chemother 62, Trimethoprim resistant 26/27 dfra cassette 19/27 Class 1 integron 0/27 SXT element 23/27 Class 2 integron (dfra1-sat-aada) 22/27 We found multiple elements stably bearing resistant dfr genes in most of the V. cholerae outbreak isolates

24 Public Health Measures and Human Well-Being Microbial life Box 30.5

25 Public Health Measures and Human Well-Being Microbial life Box 30.5

26 Disease prevention & antimicrobial use reduction Adapted from Okeke IN, Klugman KP, Bhutta ZA, Duse AG, Jenkins P, O'Brien TF, Pablos-Mendez A, Laxminarayan R. Lancet Infect Dis Sep;5(9): Reducing undesirable selective pressure Diagnostics Drug quality assurance Treatment guidelines Prescriber education Patient education Treatment strategies Combination therapy Cycling Drug heterogeneity Reducing spread Water and sanitation Hand hygiene Vaccination

27 Acknowledgements The Wellcome Trust/ GARP Center for Global Development, Disease Control Priorities Project Society-in-Science: The Branco Weiss Fellowship Koshland Integrated Natural Science Center at Haverford College

28 % of infections The ways and means for putting medicine in order must take account of the conditions of life and work among the people whom it must serve. Walton H. Hamilton, pfcrt K76T conferring chloroquine resistance dhfr C59R conferring pyrimethamine resistance years after chloroquine replacement with sulfadoxinepyrimethamine Penicillin Streptomycin Tetracycline Erythromycin Vancomycin Gentamicin Quinupristin-Dalfopristin Linezolid

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